Infant Toddler Development TrainingModule 6, Lesson 2

Nutritional Risk and Assessment

The presence of any indicators of nutritional risk warrants a nutritional assessment by the primary medical provider. The primary medical provider generally monitors nutrition as part of routine care. This is even more important for the child with chronic health conditions. The pediatrician or primary medical provider may refer a child with chronic feeding issues or several nutritional risks to a pediatric nutritionist. Indicators of nutritional risk include altered growth, altered appetite, and medications that alter the appetite or interfere with the absorption or excretion of nutrients. Other risk factors related to nutrition are an increase or decrease in energy needs, metabolic disorders, impaired mobility, decreased cognitive functioning and increased cardio-respiratory or physical effort. Another risk factor is the documentation of poor feeding skills by either the caregiver or child.

While visiting the home or child care site, the ITDS should be alert to lead poisoning risks such as peeling paint in older homes or play areas consisting primarily of loose dirt without grass or other covering. Screening for lead exposure should be part of the routine medical care for all infants and toddlers. Preventive steps include frequent hand and toy washing and provision of snacks high in calcium, iron and vitamin C as children with empty stomachs or poor diet absorb more lead. High blood lead levels have been associated with learning disabilities, anemia, hearing loss and behavioral problems.

Medical and Feeding Histories

Nutrition is assessed by monitoring the child's growth rate over time and by an analysis of the medical and feeding histories. The medical history will include illnesses and medications. The feeding history includes food content and caloric intake and excretory output, developmental feeding skills, daily routines related to feeding, and the environment where feeding occurs. Not only is history important to establish a baseline, but the history also can provide clues to causes of nutritional and/or feeding difficulties.

When taking a feeding history it is important to ask:

How much?

How often?

What types?

Feeding routines?

Where does feeding occur?

Who is the primary feeder?

Are there difficulties with feeding such as choking, gagging, coughing, vomiting, or ruminating with certain foods and not with others?

Does the child refuse certain foods or is the child overly selective with great restriction of food types?

Does the child refuse foods of certain textures?

How long and when did feeding issues begin or occur?

Physical Exams and Laboratory Tests

The physical exam and any laboratory tests follow the history. The physical exam includes growth parameters such as length or height and weight. The developmental history and assessment are as important as the physical exam and history when assessing for nutritional risk. The presence of developmental disability or delay impacts what the child may consume. Delays in cognition will usually result in delays in adaptive skills such as finger and spoon feeding and moving from liquids to solids.

Social and Caregiver History

After obtaining a nutritional history and performing a physical exam of the infant or toddler, the primary medical provider will take a social and caregiver history to ascertain if there are maladaptive beliefs about food. The physician is also informally assessing the caregivers' ability to understand a nutritional plan and medical advice. The physician may be considering questions such as:

Are there factors of cognitive ability related to the caregivers?

Are there financial strains in the home?

Is there support for the primary caregiver (usually the mother but not always)?

Is there history of substance abuse or is there a physical or mental condition of the caregiver that could impact the nutritional well being of the child?

The physician also needs to ascertain if there are genetic patterns that are common to the family such as short stature. Gathering this information would help the physician determine whether this could be a genetic indicator or if malnourishment is a concern. The ITDS may also explore and discuss cultural beliefs in a sensitive manner to determine if these values are compatible to the nutritional plan of care.

Even in the United States there are families who do not have enough food to eat. To learn the percentage of families who experience the lack of food necessary to maintain a healthy lifestyle please go to Food Insecurities for a required reading.